Name

First Name

Last Name

Email Address

Phone Number

(This will forever remain private and secure)

Height

Age

Birthday

How did you hear about us?

Why are you here? What is your motivation/drive?

Have you ever worked with a nutritionist?

List the "diets" you've tried (if any):

BACKGROUND

When was your last physical with a lab panel?

What are your current medical concerns?

Please note any chronic pain, digestion issues, headaches, high blood pressure, pre-diabetes, etc.

Current supplements/medications? Please include dosages.

Please include dosages. If you are on birth control, please note what type.

Do you have kids? Ages? Any pregnancy issues?

Do you struggle with constipation or loose stool?

Are you bloated and/or gassy regularly?

Please describe your bowel movements. Frequency? Consistency?

Do your biological parents have a history of Type 2 diabetes, addiction, heart disease, high blood pressure, or cancer?

Have you ever battled with anxiety or depression?

Please note any bouts of situational depression or anxiety.

Do you have a history of restrictive eating, disordered eating, anorexia, bulimia, or binge eating?

If you are female, please describe your menstrual cycle.

Please note any recent changes in period duration, frequency, intensity, etc.

Please describe any wellness services you frequent: chiropractic services, acupuncture, holistic practitioners, etc.

Activity/movement

What physical activities do you enjoy?

Please note any sports or activities you enjoy.

Have you had any major physical injuries?

Please note any broken bones, surgeries, torn tendons, etc.

Do you currently strength train? Please explain.

How often do you currently exercise? What type(s) of exercise?

Body image

Do you feel good about yourself/confidant most of the time? Please explain.

Do you often compare yourself to others?

Name at least five strengths/traits that you love about yourself:

How often do you use social media?

Nutrition/Lifestyle

Do you use food/drink as stress relief, reward, etc. ?

What is your food value (vegetarian, paleo, vegan, etc)?

Do you have any food allergies or aversions?

How much caffeine do you drink daily? Are you sensitive to caffeine intake?

Do you use alcohol or recreational drugs?

How much water do you consume each day?

How many cups of vegetables do you eat per day on average?

What is your average daily schedule? Please include what time you wake up, commute length, work hours, lunch and dinner time, scheduled workouts, and bedtime.

For example: 5 am wake Coffee 6-7 Am Run Shower Drive 9-10 am @ Work at 10 am 10 am breakfast 2 pm Lunch 4 pm Grab Snacks 6-7 pm Drive Home 8 pm Dinner 11 pm Bed

How often do you cook? Do you enjoy cooking?

Please check the following kitchen items you own/use:

Blender

Slow Cooker/Crock Pot

Food Scale

Oven

Microwave

Skillet

Spiralizer

Quality Knife Set

Please check the following skills you have practiced:

Chopping and storing veggies for the week

Roasting veggies

Freezing meals

Cooking 1-2 large meals on the weekend for the week

Creating a meal plan for the week

Creating a shopping list

Carrying portable non-perishable snacks

Ordering from a menu but asking for amendments/substitutions

How often you eat seated at a table without distractions (TV, phone, etc.)?

Do you eat quickly?

Do you often eat until you are uncomfortable or do you stop eating when you are 80% full?

Do you meditate or practice yoga?

What is your social support system like? Who lives with you? What activities do you do with friends?

What activities do you enjoy doing at home?

What is your "night routine" like? How many hours of sleep do you get a night?

Lifestyle: what are two lifestyle habits that you want to change?

Are you willing to prioritize weekly or bi-monthly coaching/accountability sessions?

Are you open to phone accountability sessions if you can not come into the office?

Have you ever used a food tracking app? Which one(s)?

Thank you for taking the time to fill out this intake form. If you have any questions before your appointment, please let us know!

Thank you

New Client Intake Form

PLEASE COMPLETE THE FOLLOWING before your intake session

1003 DIAMOND AVE. SUite 201, SOUTH PASADENA, CA 90310

info@bairdwellness.com • (626) 354-5319